Replacement

MARJORIE A. AMBOS,1 MORTON

Lipomatosis
A. BOSNIAK,1 RICHARD

of the Kidney
GORDON,2 AND MANUEL A. MADAYAG1

Replacement lipomatosis and renal sinus lipomatosis are parts of a spectrum of fatty replacement of destroyed or atrophic renal tissue. When long-standing inflammation exists In a kidney, especially with calculus disease, replacement lipomatosis may be the end result. Awareness of this process along with the specific radiologic findings will allow a correct preoperative diagnosis.

Case This

3 53-year-old male had been followed in clinic for many

years

for multiple

renal

calculi.

He was admitted

to the hospital

because

of a right

flank

mass.

A plain

film

of the abdomen

demonstrated

a soft tissue as well as three right renal not visualize on urography.

mass in the region of the right kidney calculi (fig. 3A). The right kidney did A right retrograde study demon-

strated Renal sinus lipomatosis tosis and as replacement

in the kidneys of older

the calculi

and stretching

of the infundibular

structures

(also referred lipomatosis)

patients and

to as fibrolipomais commonly seen

is well known to

most radiologists. However, what is not generally appreciated is that renal sinus lipomatosis is the minimal form of a spectrum of changes in the kidney associated with increased amounts of renal sinus, perihilar, and penrenal fat. The most marked form is a relatively rare process known as replacement lipomatosis in which there is so much loss of renal parenchyma that the entire
kidney is replaced by adipose to tissue. While review the this entity is in

(fig. 38). Angiography showed atrophy of right intrarenal arteries with stretching over a relatively lucent area in the central portion of the kidney (figs. 3C and 3D). The right kidney was removed and the cortex found to be markedly atrophied. The bulk of the mass was made up of fibroadipose tissue (fig. 3E). Microscopically, chronic inflammation was observed in the penirenal tissues.
Case This 4 90-year-old male was admitted to the hospital with acute

well
contains

known
few

to pathologists,
references

the

radiologic

literature
findings

urinary retention. Past history and physical noncontributory. An abdominal radiograph right renal staghorn calculus with a reniform
ing it (fig. 4). Intravenous urography revealed

examination were demonstrated a lucency surrounda nonfunctioning

it. We

replacement lipomatosis picture with four cases.

Case
Case 1

and

illustrate its radiographic

Reports

right kidney. A colonic carcinoma pitahization and surgery performed. postoperative complications. At autopsy the right renal cortex
thick. A staghorn calculus filled

was discovered The patient was found

the collecting

during expired

hosfrom 2 mm
The

to be only
system.

This 72-year-old male was admitted to the hospital with gross hematuria. Prior history was unremarkable. On rectal examination an enlarged prostate was palpated. As part of the intravenous urogram the preliminary film of the abdomen showed an area of lucency in the region of the right kidney. After injection of contrast media, marked atrophy of the parenchyma of the

region between the abundant fibroadipose

kidney.

calculus tissue,

and the cortex and similar tissue

was filled surrounded

with the

Discussion The
and which

lower

pole of the right kidney

with fatty replacement

was noted
consistent hematuria

terms
renal normal

fibrolipomatosis,
sinus lipomatosis renal sinus and

replacement
have all been fat

lipomatosis,
used increases inter-

(fig. 1). An angiogram revealed fine mrregularvessels, with chronic inflammation at the lower pole. Since

changeably

to denote

a condition

of varying
penirenal

severity

in
in

was felt to be secondary to prostatic disease and the angiogram was consistent with chronic infection, surgery was not performed.
Case 2

amount and replaces renal parenchyma [1, 2]. Actually these terms represent a spectrum of changes due to one basic process: an increase in fatty tissue in and about
the kidney associated with renal

This 66-year-old female was admitted to the hospital with a 3 week history of fever and chills. A left staghorn calculus had been removed 21 years earlier. An abdominal radiograph demonstrated increased lucency and a calculus in the region of the
right The kidney right (fig. kidney 24). was This kidney and did not visualize during

[3].
mildest the

We
sixth

use
and

the
most

term
common

renal
form

sinus

atrophy or destruction lipomatosis for the usually renal the occurs parenchyma fibroadiin

which

or seventh (senile

decade atrophy).

as normal In this

atrophies

instance

urography.
removed, pathologic examination

showed marked atrophy of renal tissue with abundant fibroadipose tissue as well as increased fibroadipose tissue surrounding
the kidney fibroadipose (fig. 28). Microscopic examination revealed tissue with lymphocytes and inflammatory diffuse cells.

pose tissue which normally surrounds the pelvis and calyces increases as more space is available due to renal tissue atrophy. We have seen this most prominently in male patients with long-standing prostatism, even without clearcut obstructive atrophy. This mild form is of no

clinical

importance.

It is a common

autopsy

finding,

and

Received October 4, 1977; accepted after revision February 21 , 1978 Presented at the annual meeting of the American Roentgen Ray Society, Boston, September 1977. Department of Radiology, New York University Medical Center, 560 First Avenue, New York, New York 10016. Address Ambos. 2Department of Radiology, Manhattan Veterans Administration Hospital, 408 First Avenue, New York, New York 10010.
Am J Roenfgenol

reprint

requests

to M. A.

cc 1978 American

130:1087-1091, June 1978 Roentgen Ray Society

1087

0361

-803X/7810600-1

087 $02.00

pathologists
the kidneys.

usually
However,

do not comment
it is of some

on it in describing
importance to radiol-

ogists cally,
cency

since renal
in the

it may simulate sinus lipomatosis

renal sinus with

a renal mass. Radiographiis seen as increased

stretching of the infundibula

lu-

structures ing them

this

secondary [1 , 4-6] (fig. become

fatty difficult

to the
5A). appearance,

increase
With

in the fat surroundknowledge from of a so 5B). are has

increasing differentiation

characteristic

mass
that

has
even

less
deposits cases

of
can

a problem.
can be easily be clearly

With
defined this due fatty

computed
identified (fig. process

tomography,

At the other end of the spectrum of the few patients in whom the renal almost entirely been destroyed, usually and calculus disease. In this situation, renal mass is gradually replaced by
repalcement lipomatosis) [3]. Since cases this

parenchyma

the

to infections destroyed tissue (i.e., of the the lipomavarying in kidthe It is a arterwith

is a part between

same process, intermediate minimal increased renal sinus tosis and the extreme changes
sis. neys These with intermediate of fatty focal and loss forms of renal degrees replacement,

exist

fat or renal
in replacement will and

sinus

lipomato-

demonstrate often develop

The

renal

sinus
the

is that
collecting

parenchyma (fig. 1). potential space between system which course It is in direct structures. the renal continuity

parenchyma

bed of fatty
ies, veins,

tissue through and lymphatics.

both the hilum of the kidney 8]. This relationship is nicely acute
Fig. 1.-Case 1, L.._.._..d replacement lipomatosis. Nephrotomogram

and the perirenal demonstrated of a calyceal

fat [2. 7. in cases of fornix where

obstruction drains out

with

rupture

of right kidney showing increased hucency and splayed suggestive of mass in lower pole of kidney. Note blunted chronic pyelonephritis, lipomatosis. parenchymal atrophy. and localized

infundibula cahyces and replacement

extravasated
then

contrast
of the

is first
kidney

seen

in the renal
the

sinus
to

and
the

through

hilum

marked cortical scarring. Subsequent angiogram demonstrated avascular mass with some inflammatory vessels. Findings are consistent with

perirenal space. An increase in the normal amount of occurs in obesity, renal atrophy of varying

renal sinus fat causes (e.g..

,. .

;=

.:

4PJ

,,,.*

:;

-:
l

I
B
L:.:

.-w-.

Fig. 2.-Case
the abdomen outline. Note

2. replacement
showing calculus areas of increased

hipomatosis

density. showing perirenal

in area of lucency Nephrectomy was performed. B, fatty replacement of all but thin rim

with infection. A, Plain film of right kidney but no clear renal (arrows) in periphery of renal Bivalved right kidney specimen of renal parenchyma. Abundant

fat is also present.

Arrow points to calculus

in renal pelvis.

Fig. renal

3.-Case pelvis and

3, replacement

hipomatosis. by contrast

not function

during

intravenous

urography.

is obscured

A, Plain film of abdomen showing three renal calculi and suggestion of mass (arrows). Right kidney did B, Right retrograde pyehogram showing one calculus as filling defect (arrow). Larger calculus occupies medium. Infundibula are stretched and splayed about relatively hucent areas. Cahyces are dilated. C. Selective

right renal angiogr#{225}m. arterial phase, showing atrophic intrarenal vessels markedly stretched and displaced by increased renal sinus fat. Arterial tree is pruned particularly in lower two-thirds of kidney. No neovascularity is present. Prominent ureteric artery courses interiorly. 0, Selective right renal angiogram. nephrogram phase, showing rim of renal parenchyma (arrows) surrounding large avascuhar relatively lucent mass occupying central portion
of kidney. E. Gross remain, particularly pathologic specimen in upper pole where of right kidney showing large emount some hydronephrotic calyces are seen. of fat replacing most of renal Note pelvic calculus (arrow). parenchyma. rh,n rim of cortex does

aging with increase chyma. occurs

and atherosclerosis). destruction of renal

and tissue.

cases Except

of

inflammation in obesity,

replacement the standing placement

lipomatosis inflammation lipomatosis.

is always and calculi. calculi were

associated

with

long-

in fat is associated This process is not in any organ which

,

with a loss specific to such

of renal parenthe kidney but as the thymus

In twoseries of represen n 79% and diagnosed

atrophies,

76% of the cases, The severe form

respectively [11 , 12]. of this condition is usually at autopsy the kidney parenchyma

or senile pancreas [1 in fat in renal sinus

3, 9, 10]. lipomatosis

While the slight increase can be secondary to severe loss that occurs of in

by the pathologist either phrectomy. Pathologically, plastic or shell fat. When the specimen renal of atrophied

or following neis a mass of hyperonly is found, a thin with rim the

obesity. mild atrophy. or parenchyma with massive

infection, the fat deposition

is opened,

1090

AMBOS

ET

AL.
of the renal mass being made up of perirenal and Varying degrees

bulk

renal sinus fatty tissue (figs. 2E and 3B). of hydronephrosis or pyonephrosis

ent, The and calculi (frequently shape making of the up staghorn) kidney the lipomatosis are are reniform

may
usually mass nests of

be

presfound. are ex-

is usually

maintained. chronic permeate to true it as it lipomas

The

fat

cells

tremely large. inflammatory

Along with the fat cells [11 , 13-15]. The but merely develops

fat does
adjacent from

not

the

parenchyma

atrophies which are

[3]. This process found within the

is distinct parenchyma.

While xanthogranulomatous occur in a chronically obstructed cally distinct granulomatous within phages the cells
[16].

pyelonephritis kidney,

may also it is pathologi-

from replacement pyelonephritis in the cells) whereas renal parenchyma. actually

lipomatosis. In xanthothere is increased lipid Lipid-laden the interstitium the lipomatosis macroof fat infiltrate

cells (foam kidney,

in replacement of the atrophying lipomatosis infection and

remain outside Why replacement of severe

renal parenchyma occurs so rarely even destruction lipomatosis sometimes

in cases

parenchymal

is not understood
The radiographic may vary. Renal

[10].
calculi features are of replacement often present, and

Fig. 4.-Case 4, replacement hipomatosis. Abdominal film showing large staghorn calculus filling right renal collecting system. Zone of lucency surrounding calculus represents fat which has replaced entire renal parenchyma. Patient subsequently expired from cardiac disease; at autopsy, large staghorn calculus was present with paper-thin rim of renal parenchyma surrounding mass of fat.

increased increased

lucency amounts

in the area of the kidney due to of fat may be recognized [8] (fig. 24).
normal water radiographic density change of the in re-

This lucency replacing the kidney is the only specific

placement lipomatosis. In some cases the fat may not be radiographically apparent, especially if a large amount

5.-Renal sinus hipomatosis. A, Tomogram of heft kidney during urography showing hucency in peripelvic portion of kidney by increased renal sinus fat. Fat extends around infundibula, splaying and stretching them. B, CT scan with intravenous contrast material showing increased lucency in peripelvic regions of both kidneys, somewhat more prominent on left. Lucency of fat is in sharp contrast to greater density of renal parenchyma.

Fig.

caused

REPLACEMENT

LIPOMATOSIS

OF

THE

KIDNEY

1091

of fibrous

results

(fig.

tissue 34).

is associated with it, and a mass As should be expected with marked there during is no renal urography of renal function so [12]. In such the sinus stretched lipomatosis

effect loss is a as

83:987-997, 1964 2. Olsson 0, Weiland

(Diagn] 1 :1061-1070,

P: Renal
1963

fibrohipomatosis.

Acta

Radiol

of parenchyma, nonvisualization retrograde dibula so

there cases infun-

3. Hamm

pyelogram characteristic

demonstrates

FC, DeVeer JA: Fatty replacement atrophy or destruction: so-called lipomatosis J Urol 141 :850-866, 1939
Gildenhorn 181 :994-997, Poilly JN, HL: 1962 Dickie J, James BrJ RN, Urol Bochier WB: Renal lAD: peripelvic sinus Renal replacement

following renal of the kidney.

JAMA a

seen in cases of lesser amounts of fatty replacement (fig. 38). If angiography is performed, stretching of the intrarenal arteries over the mass of renal sinus fat and atrophy
of the vessels (figs. 3C and with loss 3D). Tumor of side vascularity branches is not is apparent present, but

4. 5. 6. 7.

lipomatosis. hipomatosis:

report
Kreel Lieberthal relation Gynecol 8. Windholz

of 26 cases.
L, Melmed

141 :257-266,
Renal

1969
fibrohipomatosis. their Surg fat

Br J Radiol

39 : 837-843, F: Perirenal

1966
and fibrolipomatosis:

some hyperemia may be seen if infection is still present [2]. The radiologic finding of a lucent mass surrounding a staghorn calculus with a nonfunctioning kidney is
pathognomonic thogranulomatous radiographic of replacement pyelonephritis appearance, and but lipomatosis might the amount (fig. 4). Xangive a similar of visualized

to replacement
Obstet F: The 61 : 794-801 roentgen

lipomatoses

of the
of

kidney.
the central

, 1935
appearance

tissue of the kidney: its significance ogy 56:203-213, 1951

9. Freimkin J: Replacement lipomatosis

in urography.
of the kidney.

RadiolJ Urol Surg Clin

Surg

fat will
more

not be as great
vascularity

and angiography will demonstrate staining. The combination of clini-

58:100-105, 1947 10. Calver H: Replacement

NorthAm 11. 12. 14:813-819, Obstet

lipomatosis
1934

of the kidney. of the fatty

cal evaluation, urography, and angiography should permit the recognition of replacement lipomatosis in most cases. Computed tomography may be especially helpful since it is able to clearly identify fat density. ACKNOWLEDGMENTS
We thank Drs. Joshua Becker and David Folhett for the use of

Kutzman
Gyriecol

A: Replacement lipomatoses 52 : 690-701 , 1931

Davidson HB: Fibrous and

kidney.

Roth Case
no.

U,

replacement

of

renal parenchyma.JAMA
13. 14. 15.
JA: Renal sinus hipoma-

111 :233-239, 1938

case 1.
REFERENCES
1 . Faegenburg D, Bosniak MA, Evans

16.

of the Massachusetts General Hospital, case N EngI J Med 290 :845-952, 1974 Exley EW, Devereaux TJ: Replacement hipomatosis of the kidney. J Urol 34 :296-301 , 1935 Rickards E: Remarks on the fatty transformation of the kidney. BrMedJ 2:2-3 1883 Hepinstall RH: Pathology of the Kidney. Boston, Little,
14-1974. Brown, 1966

Records

tosis:

its demonstration

by nephrotomography.

Radiology